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Superficial, Cutaneous and Subcutaneous Fungal Infections

Superficial, Cutaneous and Subcutaneous Fungal Infections. Jarrod Fortwendel, PhD Department of Microbiology and Immunology jfortwendel@southalabama.edu MSB 2142 Nov. 18-22, 2013. Tinea Capitis in an Adult Woman.

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Superficial, Cutaneous and Subcutaneous Fungal Infections

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  1. Superficial, Cutaneous and Subcutaneous Fungal Infections Jarrod Fortwendel, PhD Department of Microbiology and Immunology jfortwendel@southalabama.edu MSB 2142 Nov. 18-22, 2013

  2. TineaCapitis in an Adult Woman • 87 yo woman presents to her doctor with a 2-year history of puritic, painful, scaling scalp eruption and hair loss • Previous treatment included numerous courses of systemic antibiotics and prednisone without success • Social history: recently acquired several stray cats that she kept inside her home • Physical exam: numerous pustules throughout the scalp, diffuse erythema, crusting, and scale extending to neck. Extremely sparse scalp hair and prominent posterior lymphadenopathy. No nail pitting. • Wood light positive • Presumptive diagnosis: TineaCapitis

  3. Cutaneous (and Superficial) Mycoses • Infections of the skin, hair, nail • Invades keratinized layers • Tinea – latin for “worm” • Subgroups of infections • Dermatophytoses – “classical ringworm” • Non-dermatophyticcutaneous mycoses… “the other superficial group”

  4. The Dermatophytes – Classical ringworm - #1 mould infection • Epidemiology • Anthropophilic, zoophilic, geophilic • Transmissible • Invade skin, hair and nails • Collectively called “tinea” • 3 major Genera: • Trichophyton • Epidermophyton • Microsporum

  5. The Dermatophytes – Classical ringworm - #1 mould infection • Epidemiology • Anthropophilic, zoophilic, geophilic • Transmissible • Invade skin, hair and nails • Collectively called “tinea” • 3 major Genera: • Trichophyton • Epidermophyton • Microsporum T. rubrum T. mentagrophytes Cause 80-90% of cases worldwide

  6. The Dermatophytes: Pathogenesis • Virulence factors and pathogenesis: • Infectious element • Arthroconidia • Keratin utilization • Keratinophilic and keratinolytic • Hair invasion/colonization • Endothrix, Ectothrix, Favic

  7. Clinical: Classified by anatomical site affected • Tineacapitis • Microsporum spp. – • M. audouinii, gray patch ringworm • M. canis, M. gypseum • Tineacorporis – point lesion  centrifugal spread – anywhere on body from eyebrow and neck “southward” • Trichophyton spp., Epidermophyton, (Also Candida) • Tineapedis • cosmopolitan • Trichophyton spp., Epidermophyton • Tineaunguium • Often as a secondary infected site • Almost any dermatophyte, espTrichophytonrubrum, (Also Candida)

  8. Tineacapitis

  9. Tineacorporis

  10. Tineaimbricata Etiology: Trichophytonconcentricum

  11. Tineacruris

  12. Tineacruris

  13. Tineaunguium - onychomycosis

  14. Tineabarbae

  15. Tineamanum Dermatology Image Atlas: Dermatology Images - dermatlas.med.jhmi.edu

  16. Tineapedis

  17. The Dermatophytes - Zoophilic

  18. The Dermatophytes - Zoophilic

  19. Laboratory Diagnosis • Requires demonstrating hyphae/arthroconidia from skin, hair, nails • Direct preparation: • Lesion scrapings/hair examined by calcofluor/KOH • Alternatively - Wood’s Light: • UV irradiation of infected hair, false positive/negative • Report: Hyphal fragments/arthrocondida seen • Culture: SDA +; SDA-CC +  LPCB

  20. Direct KOH prep: Hyphal fragments seen http://www.mycology.adelaide.edu.au/virtual/2009/ID2-Oct09.html

  21. The Dermatophytes: Morphology Epidermophytonspp. - Smooth walled macroconidia borne in clusters of 2 or 3; no microconidia Trichophytonspp. - Rare, smooth, thin-walled macroconidia; numerous spherical or teardrop shaped microconidia Microsporumspp. - Numerous, large, thick, rough-walled macroconidia; rare microconidia

  22. Treatment of the dermatophytoses • Localized cutaneous - topical agents • Clotrimazole (Lotrimim), Miconazole (micatin) • Tolnaftate (tinactin), terbinafine (lamisil) • Hair, nails – oral therapy • Fluconazole, itraconazole, griseofulvin • Griseofulvin • Concentrates in newly keratinized layers of cells • Virtually eradicated epidemic tineacapitis; used in tineaunguium and extensive infections. • Recurrences are common

  23. Non-dermatophyticOnychomycosis: • Candida spp. • Fluconazole • Scopulariopsis spp. • Scytalidium spp. • partial surgical nail removal + antifungal • **Possible other nail pathogens: • Aspergillus spp. • Fusariumspp. • Acremoniumspp. **nail pathogen vs. saprobe on abnormal nail material ** Must have: > 1 KOH positive!! > culture positive isolation of same agent!! **R/O fungal contamination of the culture**

  24. Case resolution… • Wood Light – positive • Skin biopsy • Enterococcus spp. and Trichophytontonsurans • Endothrixdermatophyte infection • Treated with griseofulvin and Selsun • New hair growth and resolution of pustular eruption at 2 week follow-up • Treatment continued for 8 weeks with complete hair re-growth and no permanent alopecia

  25. Superficial Mycoses • Tineaversicolor – AKA pityriasisversicolor • Malesseziafurfur • Tineanigrapalmaris • Hortaea (Exophiala) werneckii • Piedra – black • Piedraiahortai • Piedra – white • Trichosporonbeigelii

  26. Superficial Mycoses • Tineaversicolor – AKA pityriasisversicolor • Malesseziafurfur • Very common – up to 60% infected population in certain tropical environments • Most common in tropic and subtropics • Person-to-person transfer • Liopophilic fungus that degrades lipids to produce acids that damage melanocytes = hypopigmented patches w/ dark skin, pink or brown w/ light skin • Little-to-no host immune reaction

  27. Tinea (pityriasis) versicolor Chest Back

  28. Skin Scraping – Direct Prep (KOH) “Spaghetti and meatballs” • Diagnosis made by direct exam • Does not culture routinely - lipophilic • Treatment: 2.5 % Selenium sulfide or topical cream azoles • Severe cases: Oral ketoconazole “collarette”

  29. Superficial Mycoses • Tineaversicolor – AKA pityriasisversicolor • Malessezia furfur • Tineanigra • Hortaea (Exophiala) werneckii • Piedra – black • Piedraiahortai • Piedra – white • Trichosporonbeigelii

  30. Superficial Mycoses • Tineaversicolor – AKA pityriasisversicolor • Malessezia furfur • Tineanigra • Hortaea (Exophiala) werneckii • Superficial phaeohyphomycosis • Solitary, irregular, pigmented macule usually on palms or soles • Tropic or subtropic • Traumatic inoculation • Not contagious • Can resemble a malignant melanoma

  31. Tineanigra – H. werneckii 2. Culture= dematiaceous, yeast-like colony in 3 weeks 4. Treatment: Topical azoles 1. KOH prep = pigmented hyphae and yeast 3. Microscopic= two-celled, cylindrical, yeast-like cells http://www.mycology.adelaide.edu.au/virtual/2007/ID2-Feb07.html http://www.mycology.adelaide.edu.au/virtual/2007/ID2-Feb07.html

  32. Superficial Mycoses • Tineaversicolor – AKA pityriasisversicolor • Malesseziafurfur • Tineanigrapalmaris • Hortaea (Exophiala) werneckii • Piedra – black • Piedraiahortae • Piedra – white • Trichosporonbeigelii

  33. Superficial Mycoses • Tineaversicolor – AKA pityriasisversicolor • Malesseziafurfur • Tineanigrapalmaris • Hortaea (Exophiala) werneckii • Piedra – black • Piedraiahortae • Tropical, poor hygiene, uncommon • Small, dark nodules surrounding hair shaft • Clumped together by cement-like substance with asci and ascospores • Diagnosis = direct exam • Treatment = haircut, washing

  34. Superficial Mycoses • Tineaversicolor – AKA pityriasisversicolor • Malessezia furfur • Tineanigrapalmaris • Hortaea (Exophiala) werneckii • Piedra – black • Piedraiahortai • Piedra – white • Trichosporonbeigelii • Tropical and subtropical, poor hygiene • Affects hairs of groin and axillae • Forms soft, white/brown swelling on hair shaft • Shaving and washing

  35. Superficial Mycoses • Tineaversicolor – AKA pityriasisversicolor • Malesseziafurfur • Tineanigrapalmaris • Hortaea (Exophiala) werneckii • Piedra – black • Piedraiahortai • Piedra – white • Trichosporonbeigelii • Other non-dermatophytic (several) • E.g. Candida, Fusarium, and more…

  36. Subcutaneous mycoses • AKA: Inoculation Mycoses – normal soil inhabitants • Primary infection in deep skin, muscle or connective tissue • Slowly progressive and chronic, usually confined • Not transmissible • Subgroups of subcutaneous mycoses I. Sporotrichosis II. Chromoblastomycosis/Phaeohyphomycosis III. Mycetoma IV. Subcutaneous Zygomycosis

  37. Sporotrichosis – Sporothrixschenkii • Epidemiology : • Decaying vegetation, esp used for mulching • Enters via splinters, thorn pricks -Occupational hazard • Clinical Aspects: • Primary nodular lesion necrotic ulcer, suppurative • Proximal lymphatics may chronically infect (dissemination rare) • Sporothrixschenckii: • Direct prep: RARE blastoconidia • Sporothrixis a thermal dimorph • At RT: DEMATIACEOUS colony, HYALINEseptatehyphae, delicate lateral conidiophores w/ delicate rosettes of conidia • At 37°C in vivo & in vitro: oval, cigar-shaped blastoconidia. • Treatment: • Itraconazole

  38. Chromoblastomycosis • Epidemiology: • tropics – PR, Cuba, Costa Rica and Brazil • Soil saprobes; dematiaceous fungi • Trauma is required, occurs when shoes are rarely worn • Clinical Manifestations: • Not contagious • Incubation unknown • Chronic skinand subcutaneous infections • Small raised papule, ulcerates & encrusts dry, raised lesion usually on foot/leg • Satellite lesions hyper-elevate - 10-15 yrs from onset

  39. Chromoblastomycosis – Clinical Manifestations

  40. Chromoblastomycosis • Laboratory Diagnosis: • Direct Prep: Copper-colored, multiple dividing cells • Three major organisms: Cladosporium, Fonsecaea, Phialophora • Culture = differ by conidial structures • Can be considered dimorphs – yeast-like in vivo, mould in vitro • Treatment: • Specific antifungals usually ineffective • Itraconazole, terbinafine, or posaconazole • Combined with 5-fluorocytosine in refractory cases

  41. Phaeohyphomycosis • Epidemiology: • Syndrome caused by more than 20 different saprobes • Fungi appear in tissue as irregular hyphae, not the sclerotic cells seen in Chromoblastomycosis • Traumatic inoculation • Clinical syndromes: • Solitary inflammatory cyst • Slow growing (months to years) • Laboratory Diagnosis: • Surgical excision of cyst = inflammatory cyst with fibrous capsule, necrosis, fungal elements • Treatment: • Surgical excision • Itraconazole, posaconazole, voriconazole, terbinafine

  42. Mycetoma • Epidemiology : • tropical & subtropical • Soil saprobes • Trauma required for inoculation • Clinical Manifestations: • Not contagious • Swollen deep seated lesion of hand or foot

  43. Mycetoma – Clinical Manifestation

  44. Mycetoma • Laboratory diagnosis: • Caused by many diverse microbes • Eumycetoma (fungal mycetoma) • Scedosporium(teleomorphPseudallescheria) • Resistant to Amphotericin B! • Actinomycetoma (actinomycoticmycetoma) • Actinomyces, Nocardia, Actinomadura, Streptomyces • Treatment: • Bacterial – antibiotics • Fungal – surgery and long-term treatment

  45. Subcutaneous Zygomycosis • Epidemiology: • Africa, India, Latin America • Traumatic implanation • Conidioboluscoronatusand Basidiobolusranarum • Clinical Syndromes: • B. ranarum– large, movable mass localized to shoulder, pelvis, hip and thigh • C. coronatus– confined to rhinofacial area • Laboratory diagnosis: • Biopsy = focal clusters of inflammation, eosinophils, zygomycetehyphae • Treatment: • Itraconazole

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